NUR 633 Module 5 Milestone Two Example

Milestone Two: A Work System Analysis of the Night-Shift Fall Response on 6 West

[Student Name]

Southern New Hampshire University

NUR 633: Informatics and Communication Technology

Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: A Work System Analysis of the Night-Shift Fall Response on 6 West

Milestone One showed that most falls on 6 West occur at night, often soon after an unanswered call or alarm, and that the patient's fall risk never leaves the electronic record. Before any solution is designed, the project needs to know how the current system produces those results. Technology added without that understanding tends to create new work, new alarms and workarounds. This milestone analyzes the night-shift fall response as a work system. It argues that the problem arises from the interaction of several systems that were each designed separately and that the requirements for any solution must address people and workflow as well as software.

The SEIPS Framework

The Systems Engineering Initiative for Patient Safety model describes a work system as five interacting components: the people doing the work, the tasks they perform, the tools and technologies they use, the physical environment and the organization, including staffing and policies. It holds that these components together shape care processes, which in turn shape patient and staff outcomes (Carayon et al., 2006). The model is useful here because falls are rarely caused by one component; they emerge when a tired nurse, an ambiguous alarm, a distant room and a staffing ratio combine at the wrong moment.

The Work System at Night

People: the night crew on 6 West is five RNs plus a single nursing assistant covering as many as 32 patients, a ratio of about one nurse to six or seven patients. Two of the five night nurses have less than a year of experience. Tasks: nurses are giving medications, managing admissions from the emergency department and answering calls, often simultaneously. Tools: four separate systems are involved. The nurse call system receives call lights and bed-exit alarms and displays them on a station console and a hallway dome light. Bed sensors trigger when weight shifts, at one of three sensitivity levels set by the nurse. Nurses carry wireless badges that receive voice calls but not alarm messages. The electronic record holds the Morse score and fall precautions in flowsheets. Environment: the unit is L-shaped, and rooms at the far end are about 60 meters from the station; bathrooms are across the room from the bed. Organization: policy requires bed alarms for any patient with a Morse score of 45 or higher, and the nursing assistant is expected to answer most calls.

Current Workflow Map

Tracing a typical night event shows the steps, and each one was confirmed by shadowing two night shifts and reviewing the nurse call log for the same hours. A high-risk patient in a far room wants to use the bathroom and shifts toward the edge of the bed. The bed sensor, set to its most sensitive level by default, triggers. The alarm appears on the station console and the hallway dome light over the room, with no indication of the patient's risk level, and sounds at the station. If no one is at the station, the alarm is heard only by staff nearby. The nursing assistant, often in another room, may not hear it. After 90 seconds without cancellation, the alarm repeats. No message reaches any nurse's badge. The assigned nurse, in a medication room, eventually hears it or sees the dome light. By then, a patient determined to reach the bathroom may already be walking. Meanwhile, the Morse score in the record has been documented but is visible to no one in this sequence. The same event during the day unfolds differently: more staff are present, the station is usually occupied and the alarm is often answered within two minutes. The contrast explains why the falls cluster at night. The technology is identical across shifts; what changes is the number of people available to hear an alarm that reaches only the station, which is itself a design flaw rather than a staffing problem alone.

Where Information Is Lost

The analysis identifies four failure points. First, the alarm carries no priority: a high-risk patient's bed exit looks the same as a low-risk patient rolling over, which contributes to the alarm fatigue documented in the literature, where most alarms are false or nonactionable (Sendelbach & Funk, 2013). Second, alarms route to a place, the station, rather than to a person, the assigned nurse or assistant. Third, the most sensitive sensor setting, chosen by default, produces many alarms for patients who are only moving in bed. Fourth, the patient-specific risk information in the record, and the individualized plan that could accompany it, never reaches the people responding. The Fall TIPS trial showed that making a patient-specific fall prevention plan visible at the bedside reduced falls (Dykes et al., 2010), which suggests that closing the fourth gap could matter as much as speeding response.

Requirements

The analysis yields requirements, stated so that any proposed solution can be tested against them. Functional requirements: R1, a fall risk flag shall pass automatically from the chart into the call platform whenever the Morse score is documented at 45 or above; R2, bed-exit alarms from flagged patients shall route to the assigned nurse's and assistant's badges with the room number and risk level, escalating to the charge nurse if not acknowledged within 60 seconds; R3, bed sensors shall default to a moderate sensitivity, with the most sensitive setting chosen deliberately for patients who meet defined criteria; R4, a patient-specific fall prevention plan shall display on the room whiteboard and the badge. Technical requirements: R5, the interface between the record and the nurse call system shall use the hospital's existing integration engine and standard messages; R6, alarm and response times shall be logged for evaluation. Human and privacy requirements: R7, badge messages shall show only the minimum information needed, such as room number and risk level, not diagnoses; R8, no requirement shall add documentation for nurses; R9, night staff shall be involved in testing before go-live.

Conclusion

The night fall response on 6 West fails at four points where systems designed separately meet: alarms without priority, alarms routed to a place rather than a person, oversensitive defaults and risk information trapped in the record. Nine requirements, grounded in the SEIPS analysis and the evidence, will guide the design and the implementation plan in Milestone Three.

References

Carayon, P., Schoofs Hundt, A., Karsh, B.-T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 15(Suppl. 1), i50-i58. https://doi.org/10.1136/qshc.2005.015842

Dykes, P. C., Carroll, D. L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., Meltzer, S., Tsurikova, R., Zuyov, L., & Middleton, B. (2010). Fall prevention in acute care hospitals: A randomized trial. JAMA, 304(17), 1912-1918. https://doi.org/10.1001/jama.2010.1567

Sendelbach, S., & Funk, M. (2013). Alarm fatigue: A patient safety concern. AACN Advanced Critical Care, 24(4), 378-386. https://doi.org/10.1097/NCI.0b013e3182a903f9